The menopause can bring a host of challenging symptoms such as mood fluctuations, difficulties in concentration, and a decline in sexual drive. Hormone replacement therapy is commonly sought to alleviate these issues, primarily focusing on restoring estrogen and progesterone levels, which drop significantly during midlife. Recent studies indicate that testosterone may also play a crucial role in managing various menopausal symptoms beyond just libido, including mood improvement and muscle retention.

While typically categorized as a male hormone, testosterone is also present in women, albeit at lower levels—approximately ten times less than in men. Dr. Sarah Glynn, a contributor to menopause treatment guidelines at the British Society of Sexual Medicine, notes that limited understanding of testosterone’s effects has hindered research in this area, but recent findings are changing that narrative. Increasing evidence highlights the hormone’s crucial role in women’s sexual health and its potential benefits for cognitive, muscular, skeletal, and urinary function.

Approximately half of a woman’s testosterone is produced by the ovaries, with the remainder being synthesized by the adrenal glands. Testosterone levels generally peak in the 20s and begin to decline gradually after age 30, with production halving by middle age. Dr. Sharon Parrish from Cornell University mentions that although this decline often coincides with menopause, it may not be a direct result of it.

We know little about the health implications of this decline, but it is evident that it can reduce sexual interest. “[Testosterone] plays a critical role in sexual function,” states Dr. Joan Pinkerton from UVA Health in Virginia, influencing factors such as sexual arousal, desire, and lubrication. Consequently, it makes sense that nearly half of menopausal and postmenopausal women experience issues with sexual desire, with a leading cause being hypoactive sexual desire disorder (HSDD)—a distressing lack of sexual fantasies or desire lasting at least six months. In a survey of 1,800 postmenopausal women in Europe, over one-third reported reduced desire and more than half indicated decreased interest in sex.

The notion that low testosterone contributes to diminished sex drive was established in the 1940s. Numerous studies have consistently shown that testosterone replacement therapy can enhance sexual function in menopausal women. For instance, a 2005 report involving 533 women who underwent hysterectomies noted that those receiving testosterone patches along with estrogen reported more satisfying sexual experiences than those on estrogen alone. A similar study in 2010 corroborated these findings with 272 menopausal participants.

In 2019, a meta-analysis encompassing over 80 studies involving 8,480 women demonstrated that testosterone treatment for postmenopausal women significantly heightened sexual desire and increased frequency of sexual satisfaction, arousal, orgasm, and overall self-esteem. This study garnered support from approximately 12 medical organizations, including the International Menopause Society, the Royal College of Obstetricians and Gynecologists, and the North American Menopause Society, which endorsed the use of testosterone for HSDD.

Testosterone enhances sex drive by interacting with brain receptors that activate the neural pathways governing desire, explains Parrish. Thus far, only four countries—Australia, New Zealand, South Africa, and the UK—have approved women-specific testosterone products. The U.S. Food and Drug Administration (FDA) has yet to approve these, citing insufficient data on potential long-term side effects. Nevertheless, Professor Parrish argues this caution is unwarranted, stating that some studies have tracked participants for years without revealing increased risks of cardiovascular, breast, or uterine issues.

“Most healthcare providers focused on menopausal women seek an FDA-approved testosterone therapy that is both safe and effective. We genuinely believe there’s an urgent need for such treatments, particularly concerning sexual health,” Pinkerton comments.

Finding the Right Balance

Some medical professionals believe that testosterone therapy can extend benefits beyond just sexual health. A 2023 analysis covering seven studies found that testosterone may contribute to increased muscle mass, reduction in body fat, and improvements in insulin sensitivity and cholesterol levels. In 2024, Glynne and her team assessed hormone therapy in 510 women experiencing perimenopause and menopause who were also on estrogen. After four months, around 50% reported fewer anxiety episodes and less crying, while approximately 40% noted improvements in mood, focus, and fatigue. More than a third experienced enhanced memory and reduced irritability. “Common feedback is that women feel more like themselves—stronger and more empowered,” states Glynn.

Yet, skepticism remains. Pinkerton cautions that many of these studies lacked control groups, relying heavily on self-reports, which raises questions about whether improvements were genuinely due to testosterone or might be attributed to a placebo effect. “There’s some evidence concerning cognition, mood, muscle strength, cardiovascular health, and bone health, but the lack of substantial randomized controlled trial efficacy and safety data doesn’t justify recommendations for these issues,” Parrish remarks.

Most clinical trials combine testosterone therapy with estrogen, though some studies indicate that testosterone alone can effectively enhance sexual function. However, due to frequent side effects such as acne and excessive hair growth, it is generally not advised. Glynne prefers to prescribe estrogen initially, adding testosterone only if symptoms remain unresolved.

Experts agree that comprehensive clinical trials focusing on testosterone’s impacts beyond sexual health are urgently needed. Questions concerning optimal timing, dosage, and duration also persist, as Pinkerton highlights.

What stands out is that many current menopause treatments fall short for numerous individuals, particularly those with a history of hormone-sensitive breast cancer who are hesitant to undergo estrogen therapy due to concerns regarding potential tumor growth or recurrence. “This represents a significant gap in knowledge, and we need more data,” Glynn concludes.